Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00164174 Renewal 10/08/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.55(a)The area around the toilet in the first aid room, was stained dark brown with black spots and marks. There were cobwebs on the upper part of the side exit door and door covered by a curtain in the first aid room. A dead cricket was found inside, by the side egress door.Clean and sanitary conditions shall be maintained in the facility.The area around the toilet has been scrubbed again, the cobwebs on the curtain in the first aid room were removed as well as the ones on the upper part of the side exit door. The dead cricket was also swept up and discarded. Attached is a photo of the area around the toilet before it was scrubbed again (Attachment #17) a photo of the floor around the toilet after it was scrubbed again (Attachment #18), a photo of the curtain in the first aid room (Attachment #19) and a photo of the egress door where the cricket was ( Attachment #20). Moving forward, a staff cleaning chart has been implemented to ensure the floors are being mopped frequently and areas are regularly being dusted and swept. Please see Attachments #17, #18, #19, #20 10/30/2019 Implemented
2380.58(a)The entire program floor area is almost entirely covered in black scuff marks.Floors, walls, ceilings and other surfaces shall be in good repair.The program floor has been cleaned again with scrub brushes and several different types of floor cleaner. Moving forward staff will pick up the chairs when moving them instead of sliding them, leaving scuff marks and damaging the finish. A staff cleaning chart has been created with a second mopping to be done during the week and staff have been instructed to clean up spills as they happen and utilizing the wet floor sign. Attached is a photo of the floor with scuffs and ground in grime (attachment #15). Attached is a photo of the program floor after a second deep scrub (attachment #16). The program is in the process of getting a new location licensed, so this program will be moving. The location address is 4646 Smith St. Harrisburg, Pa 17109, less then a mile from the current location. Please see Attachments #15 and #16. 10/30/2019 Implemented
2380.70(d)The first aid kit in the first aid area was not equipped with a thermometer or other temperature gauging equipment.First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors.A thermometer has been placed in the first aid kit and going forward all first aid kits will contain a thermometer or other temperature gauging equipment. Attached is a photo of the First aid kit and the thermometer inside (Attachment #14) Please see attachment #14. 10/30/2019 Implemented
2380.70(e)The first aid kit in the first aid area was not equipped with first aid manual.A first aid manual shall be kept with each first aid kit.A first aid manual has been placed in the first aid kit and going forward all first aid kits will contain a first aid manual in the first aid kit. Attached is a photo of the First aid kit and the manual inside (Attachment #14) Please see attachment #14. 10/30/2019 Implemented
2380.90(a)The front, main, two-door exit door does not have a sign bearing the work "Exit" on or near the exit.Signs bearing the word ``EXIT¿¿ in plain, legible letters shall be placed at exits.All exits will be marked with a sign bearing the word ¿Exit.¿ Provided is a photo of the new exit sign (Attachment #13). Please see attachments #13 10/30/2019 Implemented
2380.113(c)(2)Individual #3's 6/12/19 physical examination form did not include the results of a Tuberculin skin test with negative results. The 6/12/19 physical examination form stated, "PPD not performed on 6/12/19." PPD stands for a Purified Protein Derivative test used to determine if one has Tuberculosis, also known as the Mantoux test. The additional physician's form behind the staff's physical, stated a PPD was administered on 3/7/19 but did not include a date the Tuberculin test was read and if it was negative or positive.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.Moving forward, UCP of Central PA's HR department will verify that all TB tests have a date when it was given, a date when the results were read, and the results listed. Attached is the document provided at the time of the site audit indicating the results, date and time of the 3/17/19 TB test (Attachment #12) Attached is a new hire physical with the date and time of the TB test as well as the date and time of the results (Attachment #11) Please see attachments #11 and #12. 10/30/2019 Implemented
2380.113(c)(3)Staff #3's 6/12/19 physical examination form did not include if she was free from communicable disease. The form was not completed with a required "yes" or "no" in relation to it's question, "Is the individual free of communicable diseases?". The form read, "please review vaccines on file." Vaccines were not included in the physical examination documentation. Staff #4's 3/14/18 physical examination form does not indicated if she is free from communicable disease. This was left blank on the form.The physical examination shall include: A signed statement that the person is free of serious communicable diseases as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease as defined in §  27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals.Moving forward, UCP of Central PA's HR department will verify all incoming physicals are completed in their entirety and that there is not any missing information. If additional pages are to be attached the HR department will work to ensure that all documents are attached to the physical as indicated. Attached is a new physical for Staff #3 which includes the indication that Staff member #3 is free of communicable disease (Attachment #9). Attached is a new physical for Staff #4 which includes the indication that Staff member #4 is free of communicable disease (Attachment #10). Attached is a new hire physical that includes the indication that the new hire is free of communicable disease (attachment #11). Please see attachments #9, #10 and #11. 10/30/2019 Implemented
2380.181(d)The 2019 annual assessment for Individual #2 was not signed or dated by the Program Specialist.The program specialist shall sign and date the assessment.Moving forward the Program Specialist will sign and date the assessment once completed. Internal Quarterly review audits will ensure that assessments are not only completed in the annual time frame but that they are signed and dated by the Program specialist. Attached you will see Individual #2¿s signed and dated assessment (Attachment #7) and a second assessment that has been signed and dated by a the Program Specialist (Attachment #8). Please see attachment #7 and #8. 10/30/2019 Implemented
2380.36(a)Staff #1's date of hire was 5/15/19 and at the time of the10/8/19 renewal inspection, did not receive training in general fire safety, evacuation procedures, responsibilities during fie drills, the designated meeting place outside the building, smoking safety procedures, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department. Staff #3's date of hire was 6/24/19 and she didn't receive the above fire safety training requirements until 7/15/19.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification o the local fire department as soon as possible after a fire is discovered.Moving forward the CPS program will provide a first day orientation to each staff member on their first day. This orientation will include fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building, smoking safety procedures, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department, as well as where to locate all emergency numbers. Attached you will find the Orientation checklist for Staff #1 (Attachment #4), the orientation checklist for Staff #3 for her facility (attachment #5) and a new hire orientation checklist from an individual just hired (Attachment #6). Please see attachments #4, #5 and #6 10/30/2019 Implemented
2380.126(a)(4)Individual #3's medication label for their inhaler stated "Albuterol Sul HFA 90 mcg, sub for Proair HFA, inhale 2 puffs four times a day as needed for shortness of breath or wheezing." The individual's medication administration records for the entire year read, "pro air hfa 90mcg inhaler 8.5 gm, inhale 2 puffs every 4 hours as needed for wheeze, cough or shortness of breath." The medication administration records and the individual's medication label instruction and name do not agree with each other.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.Going forward all pharmacy labels and Medication Administration Record sheets will contain the same information. The pharmacy label will be used to create the MAR and all staff will ensure the medication matches the MAR on a monthly basis when they create a new MAR. Attached is the Current Label for Individual #3 ( Attachment #1), the old MAR (Attachment #2), and the new corrected MAR matching the pharmacy label (Attachment #3). Please see attachments #1, #2, and #3. 10/30/2019 Implemented
2380.126(a)(7)Individual #3's medication label for their inhaler stated "Albuterol Sul HFA 90 mcg, sub for Proair HFA, inhale 2 puffs four times a day as needed for shortness of breath or wheezing." The individual's medication administration records for the entire year read, "pro air hfa 90mcg inhaler 8.5 gm, inhale 2 puffs every 4 hours as needed for wheeze, cough or shortness of breath." The medication administration records and the individual's medication label instruction and name do not agree with each other.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.Moving forward all pharmacy labels and Medication Administration Record sheets will contain the same information. The pharmacy label will be used to create the MAR and all staff will ensure the medication matches the MAR on a monthly basis when they create a new MAR. Attached is the Current Label for Individual #3 ( Attachment #1), the old MAR (Attachment #2), and the new corrected MAR matching the pharmacy label (Attachment #3). Please see attachments #1, #2, and #3. 10/30/2019 Implemented
Article X.1007The United Cerebral Palsy of Central Pennsylvania is required to meet all requirements of Article X of the Public Welfare Code and of the applicable statutes, ordinances and regulations (62 P.S. § 1007) including criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 -- 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff #1 was hired on 5/15/19; the criminal history check was not requested by the time of the renewal inspection on 10/8/19.When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.The temp agency was contacted and UCP was provided with the missing criminal history backgrounds of staff #1 verifying that the DSP had their clearances and physicals completed on time and prior to working with individuals. Beginning immediately UCP will ask the temp agency to provide a copy of their staff's physical and criminal clearances to UCP to verify the appropriate checks have been completed. The program supervisor will be responsible for ensuring the request is made to the temp agency. The program managers will monitor this practice monthly. UCP will conduct internal audits by external team members and will verify that the clearances are kept on site by UCP. see attachment 10/30/2019 Implemented
SIN-00144265 Renewal 10/25/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #1 ( Karen) does not have a current physical which was to be completed by 6/1/18Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.¿ This regulation is important to accurately document the individual¿s current health status and to ensure that they have current PPD test documentation and other required immunizations. ¿ The individual #1 did not have a current 2018 annual physical in her record. ¿ This occurred because Individual #1¿s annual physical had been completed in a timely manner, however, due to the temporary relocation of the individual¿s former day program the form had not yet been placed in the individual¿s record and staff had not been able to enter the old program location to obtain the form. ¿ Program Specialists were retrained on 55 PA Code Chapter 2380.111 (a). (Attachment #1) ¿ For immediate corrective action, the Program Specialist notified the individual¿s residential provider and had them fax a copy of the individual¿s current 2018 physical to the day program. (Attachment #11). To evidence recent compliance in this area, a recent annual physical received in a timely manner is submitted. (Attachment #12) ¿ Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #10) 11/07/2018 Implemented
2380.131(b)The White refrigerator in the dinning area there was spilled sticky substance on the inside of the door and something spilled- red under the bottom drawers. In the Black refrigerator in the freezer there was something spilled -purple. Both refrigerators appeared to need to be cleaned more frequently.The dining area shall be clean and sanitary.¿ This regulation is important to ensure that the program maintains a healthy workplace by ensuring that the refrigerators are cleaned on a regular basis to reduce the risk of possible contamination and reduce the chance of food borne illness. ¿ The day program has two refrigerators and both refrigerators were in need of being cleaned. ¿ This occurred due to program specialists failing to check to ensure that the refrigerators are cleaned on a regular basis. ¿ Program Specialists have been retrained in 55 PA Code Chapter 2380.131 (b). (Attachment #1) ¿ Program Specialists will ensure that the refrigerators are cleaned at least on a weekly basis. Staff will be assigned to cleaning assignments on a daily basis (Attachments #2 and #3). ¿ As immediate corrective action, Program Specialists have ensured that the refrigerators were cleaned and sanitary, as evidenced by the pictures attached (Attachments #4, #5, #6 and #7). ¿ As a preventative measure to ensure perpetual readiness and on-going compliance, Program Specialists will complete random checks of completion of cleaning assignments on a daily basis. (see Attachment #3). 11/07/2018 Implemented
2380.181(e)(10)Individual #1's LMH was not updated with the 9/10/18 assessment. The LMH was exactly the same as the 2017 assessment.The assessment must include the following information: A lifetime medical history.¿ This regulation is important to accurately document historical medical events and care for the individual to be included in the assessment. ¿ A lifetime medical history was included with the 2018 assessment, however, the LMH hadn¿t been updated from the previous year, as the LMH was completed by the individual¿s residential provider and wasn¿t updated for 2018 as of the date of the individual¿s assessment. ¿ Program Specialists were retrained on 55 PA Code Chapter 2380.181(e)(10). (Attachment #1) ¿ Program Specialist will ensure that all individuals have their Lifetime Medical History attached to their assessment completed annually as evidenced by Attachment #8, which was the immediate corrective action. To evidence recent compliance in this area, a recent assessment is submitted with LMH attached. (Attachment #9) ¿ Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #10) 11/07/2018 Implemented
2380.186(b)PS & Individual Sign and date- Individual #1 & #2 did not date the ISP reviews when completed. There is no place on the form for the Individual to date when the ISP reviews where reviewed with them.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.This regulation is important to ensure that service outcomes and objectives are appropriate, meet the needs for the individuals' meaningful skill-building, as well as document progress or need for revision of the outcome(s). ISP review was not dated by Individual #1 & Individual #2 when it was completed. This occurred because there is no place on the form for the individual to date when the ISP reviews were reviewed with them. ISP review form was revised to include a space for the individual to date when the Quarterly Review is reviewed with them. (attachment #13) Program Specialist has provided Quarterly Review 1 1/5/18 to evidence recent compliance across records for the Individual to date the review of the Quarterly Report. (attachment #14) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (attachment #10) 11/07/2018 Implemented
SIN-00122442 Renewal 11/02/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(a)There was no fire drill held in October 2017.An unannounced fire drill shall be held at least once a month.Program Supervisor, Manager, and Director confirm that a fire drill was not documented in October 2017. This immediate correction cannot be made to the existing documentation retroactively. However, review has shown that other records are compliant in this area (Attachment #16). Supervisor has been retrained in accurately documenting monthly fire drills to ensure compliance with this regulation. Program Manager will monitor fire drill records in advance of month ending to ensure timely completion and documentation. Staff were inserviced on all citations received and this plan of correction. (Attachment #1) Quarterly audits of fire drill records will be completed program-by-program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #6) 12/15/2017 Implemented
2380.111(c)(3)Individual #2 physical exam 5/3/17 did not contain the immunizations.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Individual #1¿s physical exam 5/3/17 was filed in record book in complete form, to include immunizations. (Attachment #14) Review has shown that other records are compliant in this area (Attachment #15). Physical letter notices sent to Supports Coordinators and providers/caregivers will specify the requirement that all sections of the physical exam are relevant and necessary to documenting and assessing the individual¿s ongoing health and must be filled out in complete form for acceptance by the program. Supervisor has been retrained in ensuring that all physical exams received by individuals receiving services from program are completed thoroughly and accurately. Staff wre inserviced on all citations received and this plan of correction. (Attachment #1) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #6) 12/15/2017 Implemented
2380.111(c)(8)Individual #1's physical exam 5/3/17 indicated no for physical limitations. The 12/29/16 assessment indicated unsteady gait- wide gait with leaning forward when walking.The physical examination shall include: Physical limitations of the individual.Individual #1¿s physical exam 5/3/17 was corrected to include physical limitations, specifically unsteady gait. (Attachment #14) Review has shown that other records are compliant in this area (Attachment #15). Physical letter notices sent to Supports Coordinators and providers/caregivers will specify the requirement that all sections of the physical exam are relevant and necessary to documenting and assessing the individual¿s ongoing health and must be filled out in complete form for acceptance by the program. Supervisor has been retrained in ensuring that all physical exams received by individuals receiving services from program are completed thoroughly and accurately. Staff were inserviced on all citations received and this plan of correction. (Attachment #1) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #6) 12/15/2017 Implemented
2380.111(c)(10)Individual #2 5/3/17 physical exam had n/a listed for information pertinent to diagnosis and treatment in case of emergency. However, Individual #3 has a seizure disorder, is a chocking risk and has unsteady gait.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Individual #1¿s physical exam 5/3/17 was corrected to include information pertinent to diagnosis and treatment in case of emergency, specifically the individual¿s documented seizure disorder, choking risk, and unsteady gait. (Attachment #14) Review has shown that other records are compliant in this area (Attachment #15). Physical letter notices sent to Supports Coordinators and providers/caregivers will specify the requirement that all sections of the physical exam are relevant and necessary to documenting and assessing the individual¿s ongoing health and must be filled out in complete form for acceptance by the program. Supervisor has been retrained in ensuring that all physical exams received by individuals receiving services from program are completed thoroughly and accurately. Staff were inserviced on all citations received and this plan of correction. (Attachment #1) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #6) 12/15/2017 Implemented
2380.113(a)Staff #1 bi annual physical was late. There was one for 4/14/15 but none for 2017.A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.Supervisor obtained updated bi-annual physical examination for staff #1. (Attachment #12) Appointment had been scheduled as immediate correction noted in internal audit prior to licensing inspection. Review has shown that other records are compliant in this area (Attachment #13). Program Manager will monitor annual physical due dates and inform Program Supervisors and appropriate staff members of upcoming due dates at least 30 days prior to expiration with a letter or email. A copy letter or email will be kept in employee file. Supervisor has been retrained in maintaining up-to-date staffing records. Staff were inserviced on all citations received and this plan of correction. (Attachment #1) Quarterly audits of staff records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #6) 11/17/2017 Implemented
2380.113(c)(2)Staff person #1 TB was late. Last one in the record was 4/16/15, there was none for 2017.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.Supervisor obtained updated TB test for staff #1. (Attachment #12) Appointment had been scheduled as immediate correction noted in internal audit prior to licensing inspection. Review has shown that other records are compliant in this area (Attachment #13). Program Manager will monitor TB due dates and inform Program Supervisors and appropriate staff members of upcoming due dates at least 30 days prior to expiration with a letter or email. A copy letter or email will be kept in employee file. Supervisor has been retrained in maintaining up-to-date staffing records. Staff were inserviced on all citations received and this plan of correction. (Attachment #1) Quarterly audits of staff records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #6) 11/17/2017 Implemented
2380.173(1)(i)Individual #2's record did not contain the DOA.Each individual's record must include the following information: Personal information including: The name, sex, admission date, birthdate and social security number.Individual¿s intake record was corrected by Program Specialist to indicate Date of Admission as per regulation. (Attachment #7) Review has shown that other records are compliant in this area (Attachment #8) Supervisor has been retrained in the thorough completion and review of intake documentation including DOA as part of enrollment and regular internal audits to ensure compliance with this regulation. Staff were inserviced on all citations received and this plan of correction. (Attachment #1) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #6) 12/15/2017 Implemented
2380.173(1)(ii)Individual #2's record under identifying marks was left blank.Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.Individual¿s intake record was corrected by Program Specialist to indicate identifying marks per regulation. (Attachment #7) Review has shown that other records are compliant in this area (Attachment #8) Supervisor has been retrained in the thorough completion and review of intake documentation to include identifying marks as part of enrollment and regular internal audits to ensure compliance with this regulation. Staff were inserviced on all citations received and this plan of correction. (Attachment #1) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #6) 12/15/2017 Implemented
2380.173(9)Individual #2's record contained the following content discrepancies; The physical says food into small pieces, ISP states food should be fine and bite size pieces. The 5/3/17 physical list the following allergies; Carbapenems, cefaclor, cephalosparins, latex, metoclorpramide, penicillin, sulfa drugs & sulfamethoxade-trimethopin. The ISP only list the following allergies; seasonal, latex, sulpha, ceclor, catEach individuals record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.Supervisor requested that SC update the ISP to have content consistent across documentation relating to diet orders and to include all allergies as documented in individual #2¿s physical examinations ¿ Carbapenems, cefaclor, cephalosparins, latex, metoclorpramide, penicillin, sulfa drugs & sulfamethoxade-trimethopin. Critical revision to ISP will be filed in individual¿s record upon completion. Review has shown that other records are compliant in this area (Attachment #11). Supervisor has been retrained in the thorough review of ISPs upon annual review as well as when critical revisions are completed to ensure consistent information across documentation and compliance with this regulation. Staff were inserviced on all citations received and this plan of correction. (Attachment #1) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #6) 12/29/2017 Implemented
2380.173(9)Individual #1's ISP listed allergies to wool and penicillin, but the 7/26/17 physical listed penicillin, wool and sulfa drugs.Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.Supervisor requested that SC update the ISP to include all allergies as documented in individual #1¿s physical examinations ¿ penicillin, wool, and sulfa drugs. Critical revision to ISP will be filed in individual¿s record upon completion. Review has shown that other records are compliant in this area (Attachment #11). Supervisor has been retrained in the thorough review of ISPs upon annual review as well as when critical revisions are completed to ensure consistent information across documentation and compliance with this regulation. Staff were inserviced on all citations received and this plan of correction. (Attachment #1) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #6) 12/29/2017 Implemented
2380.181(e)(3)(iv)Individual #2's 12/29/16 assessment did not contain any progress or growth in personal needs with or without assistance from others. This assessment was almost word fro word from the 2015 assessment.The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others.Program Specialist completed an addendum to the assessment dated 12/29/16 to include information on the individual¿s progress and growth in the area of personal needs with or without the assistance of others. (Attachment #4) Review has shown that other assessments are compliant in this area (Attachment #5) Supervisor has been retrained in the completion of assessments that are up-to-date, accurate, and comprehensive when speaking about progress and growth in the area of personal needs. Staff were inserviced on all citations received and this plan of correction. (Attachment #1) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #6) 12/15/2017 Implemented
2380.181(e)(4)Individual #2's 12/29/16 assessment only indicated the need of 1:1 staff support, however Individual #3 required staff visual at all times and arms length supervision in the program and in the community.The assessment must include the following information: The individual's need for supervision.Program Specialist completed an addendum to the assessment dated 12/29/16 to include the specific information that the individual¿s 1:1 supervision is arms¿ length. (Attachment #4) Review has shown that other assessments are compliant in this area (Attachment #5) Supervisor has been retrained in the completion of assessments that are up-to-date, accurate, and comprehensive when speaking about oversight levels. Staff were inserviced on all citations received and this plan of correction. (Attachment #1) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #6) 12/15/2017 Implemented
2380.181(e)(13)(ii)Individual #2's 12/29/16 assessment did not contain any progress or growth in motor and communication skills. This assessment was almost word fro word from the 2015 assessment.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas:  Motor and communication skills.Program Specialist completed an addendum to the assessment dated 12/29/16 to include information on the individual¿s progress and growth in the area of motor and communication skills. (Attachment #4) Review has shown that other assessments are compliant in this area (Attachment #5) Supervisor has been retrained in the completion of assessments that are up-to-date, accurate, and comprehensive when speaking about progress and growth in the area of motor and communication skills. Staff were inserviced on all citations received and this plan of correction. (Attachment #1) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #6) 12/15/2017 Implemented
2380.181(e)(13)(iii)Individual #2's 12/29/16 assessment did not contain any progress or growth in personal adjustment. . This assessment was almost word fro word from the 2015 assessment.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Personal adjustment.Program Specialist completed an addendum to the assessment dated 12/29/16 to include information on the individual¿s progress and growth in the area of personal adjustment. (Attachment #4) Review has shown that other assessments are compliant in this area (Attachment #5) Supervisor has been retrained in the completion of assessments that are up-to-date, accurate, and comprehensive when speaking about progress and growth in the area of personal adjustment. Staff were inserviced on all citations received and this plan of correction. (Attachment #1) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #6) 12/15/2017 Implemented
2380.181(e)(13)(iv)Individual #2's 12/29/16 assessment did not contain any progress or growth in socialization. This assessment was almost word fro word from the 2015 assessment.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization.Program Specialist completed an addendum to the assessment dated 12/29/16 to include information on the individual¿s progress and growth in the area of socialization. (Attachment #4) Review has shown that other assessments are compliant in this area (Attachment #5) Supervisor has been retrained in the completion of assessments that are up-to-date, accurate, and comprehensive when speaking about progress and growth in the area of socialization. Staff were inserviced on all citations received and this plan of correction. (Attachment #1) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #6) 12/20/2017 Implemented
2380.181(e)(13)(vi)Individual #2's 12/29/16 assessment did not contain any progress or growth in community-intergration. This assessment was almost word fro word from the 2015 assessment.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration.Program Specialist completed an addendum to the assessment dated 12/29/16 to include information on the individual¿s progress and growth in the area of community integration. (Attachment #4) Review has shown that other assessments are compliant in this area (Attachment #5) Supervisor has been retrained in the completion of assessments that are up-to-date, accurate, and comprehensive when speaking about progress and growth in the area of community integration. Staff were inserviced on all citations received and this plan of correction. (Attachment #1) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #6) 12/15/2017 Implemented
2380.185(b)Individual #1's assessment stated not safe with sharp objects, ISP stated not aware of kitchen safety and kept locked and not available access for safety at program. During the walk thru of the program kitchen are, sharp knives and a pizza cutter was accessible in cabinet above the sink.The ISP shall be implemented as written.Program Supervisor locked all sharp objects in a key-locked cabinet in the Supervisor¿s office, which is also kept locked when not occupied. This location is not accessible to individuals. This is evidenced by photographs (Attachment #2) Review has shown that other programs are compliant in this area, evidenced by photographs (Attachment #3) Staff have been retrained in the area of ensuring safeguards that are documented in individuals¿ records, including use of sharp objects. Staff were inserviced on all citations received and this plan of correction. (Attachment #1) Supervisor will ensure that ISP is implemented as written and that staff are informed of such safeguards. 11/06/2017 Implemented
SIN-00102312 Renewal 10/13/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(13)(i)Individual #1's assessment dated 1/28/16 did not include progress and growth over the last 365 calendar days in health.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Health.The regulation was reviewed with the Program Supervisor on 10/28/2016 by the Assistant Director (Attachment #3). An assessment completed since the licensing date shows the invidividuals progress and growth over the last 365 calendar days and current level in the area of Health (Attachment #4). The Assistant Director will complete random file checks to insure compliance with the regulation. 10/28/2016 Implemented
2380.184(a)(1)(iii)Individual #2's annual Individual Support Plan meeting held on 8/24/2016 did not include a direct service worker in attendance.The plan team shall participate in the development of the ISP, including the annual updates and revisions under §  2380.186 (relating to ISP review and revision).A plan team must include as its members the following: A direct service worker who works with the individual from each provider delivering a service to the individual.The Program Supervisor was trained on the regulation on 10/28/2016 by the Assistant Director (Attachment #1). There have not been any ISP meetings since licensing, the most recent ISP meeting occurred on 8/15/2016 which did have a direct service worker in attendance (Attachment #2). The next scheduled ISP meeting is 12/08/2016 and a copy of the ISP signature page will be forwarded on 12/9/2016. The Assistant Director will complete random file checks to insure compliance with the regulation. 12/09/2016 Implemented
SIN-00085140 Renewal 10/20/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.33(b)(1)The assessments for Individual #2 dated 10/31/13 and 10/29/14 were written by direct support staff and only reviewed by the program specialist. The direct support staff's handwriting was the only writing in the assessment. The program specialist shall be responsible for the following: Coordinating and completing assessments.2380.33(b)(1) The regulation was reviewed with the Program Supervisor by the Assistant Director on 11/16/2015 (Attachment #37). An electronic version of the annual assessment is now being used in all day programs. A recently completed annual assessment for individual #2 is included for review (Attachment #38). Implemented
2380.33(b)(18)Individual #1 had a seizure disorder. His Individual Support Plan (ISP) stated that his seizures could last 3-4 mins. He did not have a seizure protocol for staff to follow if he had a seizure at the day program. There was no documentation that any staff working at the facility had training on seizures/protocols/types of seizures/how to recognize seizures/etc. Individual #1's ISP did list some symptoms that he exhibits during a seizure (clicking noise, eyes fluttering, etc). However, his start date at the day program was 1/5/15 and only Staff #1 and #2 were trained on his ISP after his start date. Individual #1 was also a choking risk and there wasn't a choking prevention plan.The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual.2380.33(b)(18) The regulation was reviewed with the Program Supervisor by the Assistant Director on 11/16/2015 (Attachment #39). The Program Supervisor received a seizure protocol written by a CSG Program Director (Attachment #40. The protocol is appropriate for day program use and was reviewed by all day program staff (Attachment #41). Implemented
2380.34Staff #3 was trained in "Job Description and Responsibilities" on 6/26/14, "Van Training and Driving Safety" on 6/21/14, "Van Training Checklist" on 6/24/14, "Alternatives Staff Manual" on 6/26/14, and "Van Training Checklist" again from 6/23/14 to 6/24/14. The Van Training Checklist included training on the accident forms to fill out in the event of a vehicle accident whether it be in staff's personal vehicles or company vans. Staff #3 recorded an incident on the Incident Log in Individual #1's program book. She recorded that on 12:05pm on 10/9/15, she was taking Individual #1 to the Grantville market and they were hit by a car at a red light. She recorded that there were no injuries and no action was taken. Under her statements, Staff #2 recorded that he notified Staff #4, the UCP Assistant Director. There wasn't a time or date listed for when Staff #4 was notified of the incident. Staff #2 also recorded on the incident log that he "spoke with Raquelle Coleman (Assistant Program Director) who said that she didn't feel we need to seek medical attention for Individual #1". Again, the log did not note when Raquelle was notified, who she was, and why she determined that medical attention did not need to be sought. After speaking with Staff #2 during the annual inspection, he clarified that Staff #1 and #3 were in the vehicle along with Individuals #1 and #3. There wasn't an incident log for Individual #3 in his program book. Medical attention was not sought for either of the Individuals. Staff #2 also stated that Staff #3 was driving her own personal vehicle when they were struck by another car. Staff #3 did not fill out any of the accident forms, did not call 911 at the scene of the accident, but instead drove her vehicle back to the program to report there was an accident. Staff #3 did not follow the Driving Policy or the Transport of Consumers in Employee Vehicles Policy. A direct service worker shall be responsible for the daily care, training and supervision of individuals.2380.34 The regulation was reviewed with the Program Supervisor and his staff by the Assistant Director on 12/9/2015 (Attachments #35 & #36). In addition to the regulation, was a review of the agency driving policy, Transport of consumers in employee vehicles and accident reporting procedures. Implemented
2380.111(c)(4)The physical exam for Individual #1 did not include a hearing exam. Everything was left blank in spots where a hearing evaluation was to be completed. There wasn't documentation of follow up by the provider to get clarification on his last examination.The physical examination shall include: Vision and hearing screening, as recommended by the physician.2380.111(c)(4) The regulation was reviewed with the Program Supervisor by the Assistant Director on 11/30/2015 (Attachment #33). Individual #1 is due for his annual physical exam by 01/19/16. The Program Supervisor will ensure that all sections of the physical exam form are complete and this information will be forwarded no later than 1/31/16. Implemented
2380.111(c)(10)The physical examination form for Individual #1 did not have a spot for emergency information. Dominic had a seizure disorder and was a choking risk. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.2380.111(c)(10) The regulation was reviewed with the Program Supervisor by the Assistant Director on 11/30/2015 (Attachment #34). Individual #1 is due for his annual physical exam by 01/19/2016. The Program Supervisor will ensure that all sections of the physical exam form are complete and this information will be forwarded no later than 1/31/2016. Implemented
2380.124(a)Individual #1's medication logs for the past year, from October 2014 until October 2015, did not have a time listed for when their calcium antacid tablet was administered. The medication logs for July and August 2015 for Individual #1 didn¿t list a time when Lorazepam was administered. A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered, and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication.2380.124(a) The regulation was reviewed with the Program Supervisor by the Assistant Director on 12/09/2015 (Attachment #31). The Program Supervisor and the two medication administration trained staff had a review of module 8 of the Medication Administration trainer¿s manual and how to accurately document a MAR (Attachment #32). The Assistant Director will do monthly MAR checks until assured MAR¿s are being documented correctly. Implemented
2380.173(1)(i)Individual #1's date of entry to the program was not in the record. The date of entry was not recorded anywhere on paper or electronically. Each individual's record must include the following information: Personal information including: The name, sex, admission date, birthdate and social security number.2380.73(1)(i) The regulation was reviewed with the Program Supervisor by the Assistant Director on 12/09/2015 (Attachment #25). The personal information form for individual #1 was updated at the time of the licensing inspection. His admission date was added as determined by attendance logs (Attachment #26). Implemented
2380.173(1)(iii)The language understood by Individual #1 was missing from their record. Each individual¿s record must include the following information: Personal information including: The language or means of communication spoken or understood by the individual and the primary language used in the individual¿s natural home, if other than English.2380.173(1)(iii) The regulation was reviewed with the Program Supervisor by the Assistant Director on 12/09/2015 (Attachment #27) The personal information form for individual #1 was updated at the time of the licensing inspection (Attachment #28). The language or means of communication spoken or understood by the individual was added at that time. All of the consumers records are update. Implemented
2380.173(9)The physical exam form for Individual #1 that was completed on 1/20/15, stated that he had no known drug allergies. On another spot on the same physical exam form, it stated Individual #1 was allergic to Divalproex Sodium and had seasonal allergies. The Individual Support Plan (ISP) for Individual #1 stated he was allergic to Depakote and had seasonal allergies. The same physical exam form stated his food was to be cut into 1 inch pieces. Individual #1's assessment only stated that he was to eat his food slowly. Individual #1's ISP stated he had a behavior support plan but that it wasn¿t restrictive and it is.Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.2380.173(9) The regulation was reviewed with the Program Supervisor by the Assistant Director on 12/09/2015 (Attachment #29). A team meeting was held for individual #1 on 10/26/2015 and the Program Supervisor requested information to update our records. The Program Supervisor then sent an email to the team on 12/11/2015, again requesting the information that is needed for our records as well as needed to update the ISP (Attachment #30). Implemented
2380.181(e)(6)The assessment for Individual #2 did not include their ability to safely use or avoid poisonous materials. The assessment must include the following information: The individual¿s ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.2380.181(e)(6) The regulation was reviewed with the Program Supervisor by the Assistant Director on 11/30/2015 (Attachment #17). The annual assessment for individual #2 was completed on 10/28/2015, including her ability to safely use or avoid poisonous materials (Attachment #18). Implemented
2380.181(e)(13)(ii)The assessment for Individual #2 did not include their progress over the last 365 calendar days and their current level in motor and communication skills. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas:  Motor and communication skills.2380.181(e)(13)(ii) The regulation was reviewed with the Program Supervisor by the Assistant Director on 11/30/2015 (Attachment #19). The annual assessment for individual #2 was updated on 10/28/2015 including progress and growth in motor and communication (Attachment #20). Implemented
2380.181(e)(14)The assessment for Individuals #1 and #2 did not contain their knowledge of water safety and their ability to swim. The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim.2380.181(e)(14) The regulation was reviewed with the Program Supervisor by the Assistant Director on 11/30/2015 (Attachment #21). The assessments for individuals #1 and #2 were updated to include their knowledge of water safety and their ability to swim (Attachments #22 and #22a). The electronic version of the assessment is being utilized and the section on water safety changed to read logically (Attachment #22). Implemented
2380.181(f)The assessment for Individual #1 was not sent to his behavior support person or his mother who were team members at the time of the assessment dated 2/18/15. The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).2380.181(f) The regulation was reviewed with the Program Supervisor by the Assistant Director on 11/30/2015 (Attachment #23). Individual #2 recently had her annual assessment updated by the Program Supervisor and sent out to all team members prior to the ISP meeting (Attachment #24). Implemented
2380.183(4)Individual #1 received 1:1 staffing at the day program. Their Individual Support Plan (ISP) included an outcome titled ¿staying active.¿ the outcome listed their 1:1 support being needed for completion of the outcome. Progress was determined when their 1:1 could "fade". There wasn't a protocol and schedule outling the specific period of time for Individual #1 to be without direct supervision or the method of evaluation used to determine progress towards the expected outcome to achieve the higher level of independence. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual¿s current assessment states the individual may be without direct supervision and if the individual¿s ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence.2380.183(4) The regulation was reviewed with the Program Supervisor by the Assistant Director on 10/28/2015 (Attachment #7). A fade plan was developed by the Program Supervisor outlining the requirements for reduction in 1:1 support (Attachment #8). A copy of the fade plan was emailed to the Supports Coordinator to update individual #1¿s ISP (Attachment #9). Implemented
2380.183(5)The Individual Support Plan (ISP) for Individual #1 did not have a protocol to address their social, emotional and environmental needs. Individual #1 was prescribed Lithium, Guanfacine Ziprasidone, and Gabapentin for Impulse Control Disorder, Aggitation, and Mood Disorder. The day program used Individual #1's behavior support plan from the residential program as their protocol to addresss the individual's social, emotional, and environmental needs. However the ISP for Individual #1 stated that the behavior support plan listed in the ISP was only used by their residential provider. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.2380.183(5) The regulation was reviewed with the Program Supervisor by the Assistant Director on 12/09/2015 (Attachment #10). A plan for addressing social, emotional and environmental needs was developed and implemented for individual #1 (Attachment #11). The SEEN plan was emailed to the Supports Coordinator to be added to the ISP (Attachment #12). Implemented
2380.183(7)(i)The Individual Support Plan (ISP) for dominic did not include his potential to advance in vocational programming. The ISP stated that Individual #1 used to work on vocational skills while he was in high school. However he graduated high school in the spring of 2014.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Vocational programming.2380.183(7)(i) The regulation was reviewed with the Program Supervisor by the Assistant Director on 12/09/2015 (Attachment #13) An email was sent to the Supports Coordinator for individual #1 on 12/11/2015 to add information to the ISP regarding potential to advance in vocational programming (Attachment #14). Implemented
2380.183(7)(iii)The Individual Support Plan (ISP) for dominic did not include his potential to advance in competitive community-integrated employment. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following:  Competitive community-integrated employment.2380.183(7)(iii) The regulation was reviewed with the Program Supervisor by the Assistant Director on 12/09/2015 (Attachment #15). An email was sent to the Supports Coordinator for individual #1 on 12/11/2015 to add information to the ISP regarding potential to advance in competitive community integrated employment (Attachment #16). Implemented
2380.184(b)Individual #1 did not sign the Individual Support Plan (ISP) signature sheet and the day program provider could not find record of his attendance to his ISP meeting.At least three plan team members, in addition to the individual, if the individual chooses to attend, shall be present for an ISP, annual update and ISP revision meeting.2380.184(b) The regulation was reviewed with the Program Supervisor by the Assistant Director on 10/28/2015 (Attachment #5). Program Supervisor did not have a copy of the signature form from the ISP meeting at the time of the licensing inspection. A copy was obtained to show that individual #1 did attend his annual ISP meeting on 1/23/15 (Attachment #6). Implemented
2380.186(c)(2)The Individual Support Plan (ISP) reviews for Individual #1 did not review his 1:1 supervision support that was needed at the day program.The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.2380.186(c)(2) The regulation was reviewed with the Program Supervisor by the Assistant Director on 10/28/2015 (Attachment #1) An ISP review was completed for individual #1 on 10/26/2015 that included a review of the 1:1 support needed at day program (Attachment #2). Implemented
2380.186(d)The Individual Support Plan (ISP) reviews for Individual #1 were not sent to his behavior support provider or their family member Joy Baskerville.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting.2380.186(d) The regulation was reviewed with the Program Supervisor by the Assistant Director on 10/28/2015 (Attachment #3). An ISP review was held for individual #1 on 10/26/2015 and copies of the ISP review were then sent out to all team members (Attachment #4). Implemented
SIN-00069873 Renewal 10/02/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)The TB test for Individual #1 was not completed in the regulatory timeframe. The prior TB testing was completed on 3/26/2012 and not again until 5/5/14.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.The Program Supervisors were trained on the regulation (Attachment #18). The TB test for an individual entering the program since the licensing inspection indicates that the TB test was completed with the regulatory timeframe (Attachment #19). Also the tracking form used by all supervisors was revised to enable the supervisor to track the dates of TB testing, especially when they differ from the individual¿s physical date (Attachment #20). ). The Program Supervisor is responsible to ensure compliance with the regulations. The Program Supervisor will review all consumer files for compliance of this regulation 02/27/2015 Implemented
2380.173(9)Individual #2's record contains a content discrepeny regarding his allergies. The physical states an allergy to amoxicillin and pollen. The ISP states an allergy to hayfever and seasonal allergies. Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.The Program Supervisors were trained on the regulation (Attachment #15). Individual #2¿s physical was changed to reflect that amoxicillin is not an allergy but a toxic reaction when given with Depakote (Attachment #16) Individual #2¿s ISP was revised, the interaction between Amoxicillan and Depakote is now noted in the medication section of the ISP, not in the allergy section (Attachment #17). The Program Supervisor is responsible to ensure compliance with the regulations. The Program Supervisor will review all consumer files for compliance of this regulation by 2/27/2015. The Assistant Director will do random consumer file monitoring throughout the year to ensure compliance. 02/27/2015 Implemented
2380.181(e)(12)The assessment for Individual #1 did not include recommendations for specific areas of training, vocational programming and competitive employment. The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.The Program Supervisors were trained on the regulation (Attachment #6). The assessment for Individual #1 was updated to include recommendations for specific areas of training, vocational programming and competitive community-integrated employment (Attachment #7). ). An assessment for MT completed after the licensing inspection is attached to show compliance with the regulation (Attachment #21). The Program Supervisor is responsible to ensure compliance with the regulations. The Program Supervisor will review all consumer files for compliance of this regulation by 2/27/2015. The Assistant Director will do random consumer file monitoring throughout the year to ensure compliance. 02/27/2015 Implemented
2380.181(e)(13)(ii)The assessment for Individual #1 did not include progress over the last 365 days in motor and communication.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas:  Motor and communication skills.The Program Supervisors were trained on the regulation (Attachment #8) The progress and growth section of the assessment for Individual #1 and #2 was revised to show the progress over the last 365 days and the current level in the area of Motor and Communication Skills (Attachment #9 and Attachment #10). An assessment for MT completed after the licensing inspection is attached to show compliance with the regulation (Attachment #21). The Program Supervisor is responsible to ensure compliance with the regulations. The Program Supervisor will review all consumer files for compliance of this regulation by 2/27/2015. The Assistant Director will do random consumer file monitoring throughout the year to ensure compliance. 02/27/2015 Implemented
2380.181(e)(13)(iii)The assessment for Individual #1 did not include progress over the last 365 days in personal adjustment. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Personal adjustment.The Program Supervisors were trained on the regulation (Attachment #11) The progress and growth section of the assessment for Individual #1 and #2 was revised to show the progress over the last 365 days and the current level in the area of Personal Adjustment (Attachment #9 and Attachment #10). An assessment for MT completed after the licensing inspection is attached to show compliance with the regulation (Attachment #21). The Program Supervisor is responsible to ensure compliance with the regulations. The Program Supervisor will review all consumer files for compliance of this regulation by 2/27/2015. The Assistant Director will do random consumer file monitoring throughout the year to ensure compliance. 02/27/2015 Implemented
2380.181(e)(13)(iv)The assessment for Individual #1 and #2 did not include progress over the last 365 days in socialization.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization.The Program Supervisors were trained on the regulation (Attachment #12) The progress and growth section of the assessment for Individual #1 and #2 was revised to show the progress over the last 365 days and the current level in the area of Socialization (Attachment #9 and Attachment #10). An assessment for MT completed after the licensing inspection is attached to show compliance with the regulation (Attachment #21). The Program Supervisor is responsible to ensure compliance with the regulations. The Program Supervisor will review all consumer files for compliance of this regulation by 2/27/2015. The Assistant Director will do random consumer file monitoring throughout the year to ensure compliance. 02/27/2015 Implemented
2380.181(e)(13)(v)The assessment for Individual #1 and #2 did not include progress over the last 365 days in recreation. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation.The Program Supervisors were trained on the regulation (Attachment #13) The progress and growth section of the assessment for Individual #1and Individual #2 was revised to show the progress over the last 365 days and the current level in the area of Recreation (Attachment #9 and Attachment #10). An assessment for MT completed after the licensing inspection is attached to show compliance with the regulation (Attachment #21). The Program Supervisor is responsible to ensure compliance with the regulations. The Program Supervisor will review all consumer files for compliance of this regulation by 2/27/2015. The Assistant Director will do random consumer file monitoring throughout the year to ensure compliance. 02/27/2015 Implemented
2380.181(e)(13)(vi)The assessment for Individual #2 did not include progress over the last 365 days in community integration. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration.The Program Supervisors were trained on the regulation (Attachment #14) The progress and growth section of the assessment for Individual #1 and Individual #2 was revised to show the progress over the last 365 days and the current level in the area of Community Integration (Attachment #9 and Attachment #10). An assessment for MT completed after the licensing inspection is attached to show compliance with the regulation (Attachment #21). The Program Supervisor is responsible to ensure compliance with the regulations. The Program Supervisor will review all consumer files for compliance of this regulation by 2/27/2015. The Assistant Director will do random consumer file monitoring throughout the year to ensure compliance. 02/27/2015 Implemented
2380.183(5)Individual #1's ISP did not include her SEEN plan. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.The Program Supervisors were trained on the regulation (Attachment #3) The SEEN plan for Individual #1 is now part of the record. The SEEN plan is attached (Attachment #4). The SEEN plan was also mailed to the SC on 12/22/2014 to be added to her ISP (Attachment #5). The Program Supervisor is responsible to ensure compliance with the regulations. The Program Supervisor will review all consumer files for compliance of this regulation by 2/27/2015. The Assistant Director will do random consumer file monitoring throughout the year to ensure compliance. 02/27/2015 Implemented
2380.186(c)(2)THE ISP review's for Individual #2 did not review his SEEN plan. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.The Program Supervisors were trained on the regulation (Attachment #1). Individual #2 had an ISP review on 11/3/2014 which included a review of his SEEN (Attachment #2). The Program Supervisor is responsible to ensure compliance with the regulations. The Program Supervisor will review all consumer files for compliance of this regulation by 2/27/2015. The Assistant Director will do random consumer file monitoring throughout the year to ensure compliance. 02/27/2015 Implemented
SIN-00056172 Renewal 11/01/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(c)(2)Staff #1 was hired on 8/5/13 and there was no indication of TB testing results on his initial physical. (c)  The physical examination shall include:(2)  Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.Program Supervisors were retrained on the regulation by the Assistant Director of Adult Services on 1/3/2014 (Attachment #1). Program Supervisors will review physicals of all prospective employees prior to attending new hire orientation to ensure that the physical is complete to include a TB test within the last 2 years. The physical forms for the 2 staff hired since the licensing inspection are attached showing that the physical and TB test requirements are in compliance with the 2380 regulations(Attachment #2 & 3). 06/26/2014 Implemented
2380.181(e)(8)The assessment for Individual #2 did not include his ability to evacuate in the event of a fire. (e)  The assessment must include the following information: (8)  The individual's ability to evacuate in the event of a fire.Program Supervisors have been retrained on proper documentation on the assessment form (Attachment 4). A current assessment for JS shows the individual's ability to evacuate in the event of a fire (Attachment #5) 01/03/2014 Implemented
2380.181(e)(13)(i)The assessment for Individual #1 did not include progress and growth in Motor and Communication skills, Personal Adjustment, Socialization, Recreation and Community Integration. Also, the assessment for Individual #2 did not include progress and growth in Socialization, Recreation and Community Integration. (e)  The assessment must include the following information: (13)  The individual's progress over the last 365 calendar days and current level in the following areas: (i) Health (ii) Motor and Communication Skills (iii) Personal Adjustment (iv) Socialization (v) Recreation (vi) Community Integration.The Program Supervisors were retrained in the proper completion of the assessment to include the individuals progress over the last 365 calendar days and current level in the following areas: (i)health (ii) Motor and Communication Skills (iii)Personal Adjustment) (iv)Socialization (v) Recreation (vi) community integration. (Attachment #6). Also attached is a current assessment showing the progress and growth for JS along with his progress and growth from his previous assessment dated 1/05/2013 (Attachment #7 and Attachment #8). 01/03/2014 Implemented
SIN-00042612 Renewal 10/11/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(3)The diptheria and tetanus immunization for Individual #2 has not been updated since 5/11/2011(c)  The physical examination shall include:(3)  Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.The Program Supervisor is responsible to ensure all physical examinations are complete. Regulation 2380.11(c)(3) was reviewed with the Program Supervisor on 10/26/2012 (Attachment #1) and the update immunization for Individual was completed on 11/26/2012 (Attachment #2). 10/26/2012 Implemented
2380.181(e)(13)(i)There is no indication of progress and growth in the health section of the assessment.(e)  The assessment must include the following information: (13)  The individual's progress over the last 365 calendar days and current level in the following areas: (i)   Health.The Program Supervisor is responsible for the content of the assesssment. Regulation 2380.181(e)(13) was reviewed with the Program Supervisor on 10/26/2012 (Attachment #3). Individual #2's assessment now includes progress and growth in the areas of health, motor & communication, personal adjustment, socialization, recreation and community integration (Attachment #4). 10/26/2012 Implemented